 This is the house health care committee and this afternoon we are taking testimony as background information to House Bill 266, which is an incremental approach to health insurance for hearing aids. Health insurance coverage for hearing aids. And so that folks who are listening to this or who listen to it later on YouTube can anticipate our health care committee will take further testimony on House Bill 266. Next Thursday, February 24 from 9 to 10 30 am. And at that time we will be hearing from some advocates for this bill and for some members of the community who will benefit from this bill. Before we begin before we go any further, I want to acknowledge that we are that we have with us, Corey, who is on the screen and doing sign language interpretation. Welcome. We appreciate your assisting us and assisting those who are watching and listening. We also have in the background, as I understand it, a live transcription, a live transcriptionist, a person who is doing live transcription as well. I think we what what might be helpful if we determine what might be helpful for us to each go around and simply say our name with representative in front of it, as we go around the table so that Corey can hear our voices and hear our name. So can we start with representative Goldman and I'm just going to ask you each to go around to say your name. I hope that you can hear through the mask, but it's representative Leslie Goldman from rocking him. Representative Peterson. Representative Elizabeth boroughs of West Windsor. Representative and Donahue from Northfield. And I'm the chair of the committee representative bill Lippert from Heinsberg representative Lori Houghton from Essex Junction representative woodman page from Newport. Representative Alyssa black of Essex representative Mari Cordes from Lincoln. Great. Thank you all. And we have Mike for on from legislative operations, assisting us in the background in case there's any technological issues, he can help problem solve for us. Thank you Mike. So with that I'm going to turn to the agenda for this afternoon for early for the next hour, we anticipate we've scheduled that amount of time, I think we'll probably need that amount of time. We'll try to cover two different pieces of information, both of which are relevant to House bill 266. One is, I want us to hear about the process and the recommendations around what are called essential health benefits. And this is a process that I will just acknowledge started last legislative session with this committee, working with the department of financial regulation. About our desire and their desire to move ahead with an assessment. And I see that I'm going to ask Emily Brown, I see, I'm looking trying to see if I have Emily. Yes, when all the witnesses if you come on the screen with your photos that'd be great. Emily, Addy, and Nissa. So, Emily, would you, perhaps, do you want to start or Addy, do you want to introduce it because my understand because the department Emily Brown is from the Department of Financial Regulation. Addy Stromelo is the Deputy Commissioner of the department for my department of health access diva. My back is here. She's the director of health care reform at the agency of human services. And Nissa James is also with us from diva. But I'm going to turn it over to Emily and perhaps I'll turn it over to you to start because the Department of Financial Regulation, fondly known as DFR is has taken a significant role in moving this forward and I believe there's also a slide deck somewhere that's someone they wish to share. So Emily, I'm going to turn it over to you. Great. Thank you. My name is Emily Brown. I'm the director of finance insurance regulation for the Department of Financial Regulation. And I'm joined, as you mentioned, by my colleagues, Addy Stromelo, Nina Bacchus and Nissa James. And so actually what we're going to do I'm going to turn it over to Addy, who will be running through some slides. I don't know. Oh, there I'm allowed to share my screen if that's okay. And is your preference that we share. Oh, display the slides, because we're, we're happy to, if that's easiest. But not now. I have it on my list, but I keep forgetting. Sorry, we were having some technical issues in the in the room. Our speaker vibrates and makes an odd noise occasionally. Hope it's not too disturbing. It's slightly disturbing to us, but we will have it addressed by our IT staff eventually. Okay, I'm sorry, I got distracted. So, Emily, you're turning this over to Addy. Yes, I'll be turning it over to Addy and should, Claire, should we share the slides that we submitted earlier or would you like, or would you like to share them. I think if we'll have to disrupt the interpreter. If the interpreter could just be spotlight when you share the screen, then I will make I will continue to be on the screen with the slides. Okay. So, can we do we know how to do that. That was my question. Yeah, let me let me share and then see if I can spotlight. Corey, do you know if that's something that the share the presenter does the person who is the host, just all you do is click on the three buttons on the top right click on them, and then spotlight or pin should be one of those options. You are you are on the screen Corey. With the upper right hand corner of the screen. Perfect. And can I just say one other piece of introduction the reason we're talking about essential health benefits. And the reason one of the primary reasons was that there is a strong interest in looking as to whether hearing aid services could be integrated into the essential health benefits like benchmark plan, which I'm, we're going to say more about right now. Okay, thank you very much. Addie strumlow deputy commissioner department of Vermont health access. And as Emily said, as soon as you started speaking at the court the interpreter left the screen so we. We need to. Apologies, I thought we were all set but clearly there's something else we need to do to ensure that sign language interpretation is seen on the screen while we're doing screen sharing. Is that my front is there anything you can assist us with or. Well, but we're good until Addie starts to speak and then. Addie can also be spotlight, and then the two of us will remain on the screen, regardless of who's talking. Should I test. Is Corey still on if I speak. That's perfect yes. We don't know what's happening out in on YouTube though. So folks this is well maybe we shouldn't show slides. We can just speak through the slides. Okay. On YouTube they see Corey. Is they can be seen on YouTube. Can you speak a couple minutes I'm getting confirmation on what is seen on YouTube. Sure. Testing. We're here to speak about essential health benefits. Just so you know I'm watching it on YouTube and then zoom at the same time and it's not showing Corey. Yeah, me too. It jumps to that. This is Jen. It jumps to the committee room when somebody in the committee room talks and then it jumps to addie when Addie talks. So for a moment I can see it Corey. Perhaps it would be most straightforward for us not to display the slides. Okay. This is Mike front and I agree. I think we, I think you either need to share slides or not. And I think with this particular issue, I would not share slides. Okay, great. I'll take them down. Okay. So we will slides will be available on the website of the house health care committee. And without trying to explain that on the legislative website, the Vermont legislature under the house health care committee. But we will provide more information as we are able to assist. Now because great spotlight feature. That's why we're seeing only one large screen. Okay, well this is. Okay, let's continue and I think we have any an illustration of the challenge of having full access. That's useful for us to struggle with. But we I just apologize. I thought we had problem solved everything ahead of time but we have not thought of everything. So let's continue. And go from here. Thank you. Once again, Addie stromello department of Vermont health access. And as you know I'm here with my colleagues from department of financial regulation and the agency of human services office of health care reform. And I wanted to highlight an update on a process which as you mentioned has been long underway related to essential health benefits. I know Emily in particular has been here recently to talk about the process that DFR convened related to a grant opportunity and then reporting out on examining additions of benefits to our essential health benefits benchmark plan. So I'm here to kind of pick up on that and clarify where we are in the process. We thought it would be helpful to first start with a refresher of what we're talking about when we talk about essential health benefits. Under federal law the Affordable Care Act. Health plans in the individual and small group markets are required to cover certain essential health benefits. The way that the federal government defines these is by a state selected essential health benefits benchmark plan. Federal regulations provide options from which states can select a benchmark plan. Another exercise that's been going on for the last year is looking at the existing benchmark plan and evaluating gaps and areas where we might want to add more benefits. One reason that this process is is what is used to add benefits into the health insurance products is that it avoids something called state defrayal. This is a federal requirement that states pay for additional insurance mandates enacted after 2012. That's a feature of the Affordable Care Act. So by adding benefits through a selection of a benchmark plan, we avoid that potential state cost. Instead the cost of any additional benefit through the benchmark plan would play out in the plan design and rate development process for qualified health plans. So maybe I'll just pause there and see if there are any questions about the process itself and then we'll get to what's happening on the state level. There are a lot of underlying questions that probably aren't clear to someone listening for the first time but I think we should continue because we use a lot of terms that are familiar to us but not familiar to everyone. Representative Coleman you have a question. I'm just wondering for clarity to say who the benchmark plan covers just to be clear on the population that this is addressing. That's a great question. It applies to the individual and small group markets in any state. And here in Vermont as you know we have a temporarily unmerged individual and small group market, also known as a qualified health plan market. This covers about 70,000 individuals in the state. And that is the population we're talking about being impacted by any changes to the benchmark plan. That's very helpful. So, so that's the federal framework. Under state law, it's the Green Mountain care board that has the responsibility of approving changes or any benefits in that qualified health plan market. And they are required to do so with recommendations from the Department of Vermont health access. So, having gone through this stakeholder group again convened by the Department of Financial Regulation. The state came together and and put together recommendations which we this week presented to the Green Mountain care board for consideration. So with respect to the benchmark plan. The federal government provides three options. If a state wants to change it. One is to pick a benchmark plan from another state. The second is to replace certain categories of benefits with those from another state. And the third is kind of a generic option which is to select a set of benefits to become the state's benchmark plan. So the recommendation that we made this week is to select that federal option three. What we recommend is that the state create a new benchmark plan, again for the qualified health plan market, which would include all the benefits in the existing benchmark plan, which is the blue cross and blue shield CDHP HMO plan. So we recommend creating that new plan and then adding a new benefit, which is hearing aid coverage. And I'll get into the specifics of what that benefit would look like, but we see that as filling a critical gap in the current benchmark plan. And then the third aspect of the recommendation is that the state submit this change to the federal government for approval for plan year 2024, which is the earliest that we could have this change go into effect. So that that is what's covered in the slides and again what we presented to the Green Mountain Care Board this week, as is our statutory responsibility but I'll just reiterate this has been a very collaborative process with our colleagues in the other agencies as well. The hearing aid benefit description would cover an annual hearing exam for adults and children based on medical necessity up to one hearing aid per year every three years. There would be no age limitations that's a federal limitation or restriction on having age limitations. And then issuers would determine the cost share amount for each plan and that's something that would play out in what is known as the plan design process that happens annually, and talks about what cost sharing each qualified health plan has. One of the considerations in making this recommendation to add hearing aids are that we expect it to improve the quality of life for many Vermonters currently unable to afford hearing assistance, specifically improved mental well being an additional in support of health and equity. This change would close a gap in Vermont's current EHB coverage. Sorry, I started to use the abbreviation essential health benefits, known as EHB Vermont is currently one of only two Northeast states without hearing aid coverage. Finally, as I mentioned, federal anti discrimination regulations require that such a benefit when medically necessary be covered without any age limitations. Because I know you had testimony from Emily earlier the session about the report and the working group we did want to mention that there were other benefits under consideration for addition into the benchmark plan. And we are not recommending those additions but would support additional exploration for future years. And Emily can speak about what that process would look like a continuation of the, the actuarial work that went into this, this presentation. I think maybe I'll pause there and happy to take questions again. It's this, we've made the recommendation to the Green Mountain Care Board, I believe they're planning to vote in the next several weeks there's a public comment period associated with that. And then, as I mentioned the plan, if approved the plan would be to then submit for the application to the federal government in April for playing year 2024. Can we just say with, can you be explicit about when we say plan year 2024. What, when that coverage would start. Yes, the plan year for this market coincides with the calendar year so we're talking about beginning January 1, 2024. And we do not have the ability to accelerate that into any earlier plan is that is that accurate. Correct. And for two reasons, one is the federal government requires a significant runway to approve these changes so the deadline that they have this may is for 2024. That's one piece. The other piece is that the plan design for 2023 has actually already been approved by the Green Mountain Care Board so as I know we've spoken about over the years that the process of designing the plans and and that whole plan to prevent body of work begins very early the previous plan year. I think to those, those outside of the world of insurance plan changes. Always find at least I'll speak for myself, I know initially was like, it was like, I couldn't believe how far in advance, one had to work to change to impact an insurance health and health insurance plan. This is having done the analysis having done now the recommendations to the Green Mountain Care Board. It sounds like it's important that the Green Mountain Care Board act before the, before a deadline coming up this spring is that correct. Correct. Or for us to get this into the 2024 plan. I see some questions in the room. Can we take questions and, and then maybe hear from Tina back as well from the Green Mountain. No, I is not from the Green Mountain Care Board. Sorry. Used to be one time. Let's call my time I think. But, okay. Question representative black to two very simple questions. I don't know does Vermont Medicaid currently cover. That's actually our next topic. So we're going to talk about that. Wait, I'll wait on that. My other question is, do we have any sense of the self insured market, how much of that self insured market takes the, the essential health benefit plan that is created and just moves that into. Their coverage as well. Great question. Yeah, I can take that one atty. So, to, to answer your question representative black, we don't see those plant the plan designs for self insured employer groups or other self employed groups. It's usually up to that group to decide what benefits they want to offer their employees. So, having this benefit added could then lead an employer to decide that they want to offer the benefit but it wouldn't require them to offer the hearing aid benefit. As I said, currently we don't, we don't have the authority to collect those plans. So we're unsure at this point how many of those plans cover hearing aids, and if, if they would decide to in the future. And I also add to that that I have asked pose the same question to blue cross blue shield who is the administrator for many of those self insured plans. They, they will try to give us an answer in some future testimony, but I don't believe they were clear as well. Also, I guess stuff there was another five check in. President bros. Just because I wasn't hearing you very well. Did you say one hearing aid per year, per year. It was every three years. The one hearing aid every three years so a person who needs to hearing aids per year. Every years. That's what I miss her. Thank you. I think we've said it, we've said it several different ways. So that's, let's say it again. My understanding is the recommended recommendation is one hearing aid per year. Every three years. Is that the recommendation. That's correct. Is that consistent with other essential health benefit plans that you have reviewed. Emily, do you want to speak to this. Yeah. And I, I can try to pull it up quickly. So when we were looking at what benefit design would make sense in Vermont. It was the request of stakeholders and after discussion in the working group. That we align the benefit with Vermont Medicaid. So if you look at Vermont Medicaid current benefit. It, it really says that hearing aids are covered subject to medical necessity. But then when we dug a little bit deeper into how Medicaid was defining medical necessity, we discovered that. Their current benefit design allowed coverage of. One hearing aid per year every three years. As, as their kind of medical necessity determination. So we felt that it was appropriate to model the benchmark plans benefit after Vermont Medicaid. So if you'll give me one second, we did look at other states hearing aid. Coverage and found that it varied throughout the Northeast, which is where we focused our analysis. States, some states did have a 36 month coverage period similar to, to what we're proposing here. There were, there was variation, for instance, Connecticut had a 24 month coverage period, while New Hampshire had a 60 month coverage period. So there were, you know, variations in either direction. And other benefit design restrictions, for instance, one, one state. Excuse me, one state classified the hearing aids as BME some states actually had age limits, which aren't currently allowed. But we, we felt that modeling the benefit after Vermont Medicaid seemed to make sense in the situation so that's, that's what we did. And that was also based on the recommendation of interested parties. That's an acronym that you used earlier. I think it was durable medical equipment that you were said, when some states. Yes, some states classify hearing aids, I believe it's Connecticut classifies hearing aids as durable medical medical equipment or DME. Okay. Any questions, representative page. Yes. I was curious to know, to these hearing aids only last three years, and you throw them away and then get another one. Do we also know what type of hearing aid this is this is going to be the cheapest of the cheap, or is it going to be, you know, middle of the road or do we have any information on the actual hearing aid itself and the quality. Yeah, so those decisions will ultimately be up to the health insurers to decide and again, using that term medical necessity, the health insurers will be required to cover hearing aids but then they will determine for instance if there's a slew of brands that cover that will be, you know, part of their covered benefit but this this benefit recommendation we're making here does not specifically refer a brand, or a type of hearing aid that will probably largely be determined by the prescribing provider. And then what what will then happen is that, for instance, if there's a certain type of hearing loss or, or level of hearing assistance that someone needs and that's prescribed by the provider, as long as it's medically necessary then that should be covered but just with all other benefits that are covered usually insurers do have certain restrictions on their benefits, one to control costs but then also so insurers can know what what is covered and know what to expect when they're using a benefit. Yeah, just follow up on that. Thank you. Follow up on that I imagine you will get a certain amount of money that you can use to purchase a hearing that would seem to me. It would be $4,000 and if you choose to get a higher quality hearing aid than that, you would be on you to pay the rest. Can you foresee something like that. Yeah, so I also just wanted to follow up. Sorry, the last question. I just lost my train of thought I'm sorry it will come back to me but to answer your question. The ACA does not allow dollar limits on benefits so in the plan document they're not allowed to say for instance will only cover up to $4,000 they they have to just say hearing aids. They can put cost share on hearing aids for instance if you if you need hearing aids and you're using your insurance plan, there might be some cost share that will be associated with using that benefit but under current insurance are not allowed to put a dollar limit. And I just remembered the last question before I forget was do hearing aids only last three years. I think there's variation with that I think some probably can last more than three years, but by putting an annual, you know, an annual allowance or an annual number in there, like what we're proposing here three years. And then kind of taking the guesswork out for insurance and the insurance company to say okay it's been three years I can now get a new pair of hearing aids or if you don't need them, you can keep the ones you have. I know we heard that with children, especially as your, your ears grow. You, they might lose hearing aids or need new ones depending so this also addresses that issue of of allowing someone who needs either replacements or maybe they're hearing loss has changed to get a new pair every three years but it wouldn't require them to Okay, and just kind of delve in just a little bit deeper. I think there's a cost share so they're not going to restrict you to a certain maker model of hearing aid are they. They could they could with their so they might an insurer might choose and I believe Vermont Medicaid does this currently. And I'm not the expert on on this by far but they can say we'll cover X Y and Z brands of hearing aids. But if there is a hearing aid that you need for your hearing loss, it should be covered. They shouldn't be able to to by restricting for instance to certain brands they shouldn't be able to then restrict your access to hearing aids so if you need a hearing aid you should be able to access one, regardless of brand but I'm going to be parameters around just like first control for instance there's certain brands that are covered under you know for contraception, and that's just a way to, you know, let insurers know as well as restrict, or I shouldn't say restrict but utilization management techniques that you know control costs but also allow people to access the benefit. Thank you. I'd like to page. Yes, I realize we're, we're dealing with hearing aids that fit inside the year, and that you can remove. Is there any surgical care. Yes, that might be covered or is that out of this year. Yes, so when we did an analysis of the current benchmark plan it was, it was discovered or it was found that cochlear implants are currently a covered benefit. The current benchmark plan cochlear implants are covered. And this would be adding the actual, as you said the in ear hearing aid as well as hearing exam for children and adults. And again, just because I know I questions have been posed to me as I've been trying to anticipate us taking this issue up there, there will be and there are no, there are no restrictions by age. It's either the essential health benefit plan recommendation so it's not like a different standard for children versus adults or adults for children. And I believe is that I want to just confirm as well because we've kind of backed into hearing about the Vermont Medicaid benefit, but you mentioned it and is it. And I'm sure that there is not a different benefit for adults versus children in Vermont Medicaid's hearing aid service benefit. So I, I don't think I can speak to that I don't believe there is that Addie, you. Okay, I'm sorry, I think I was speaking to someone from diva at that point. Okay, no, no, I mean, I was recalling a conversation that I had, but I was trying to confirm have that confirmed publicly if I'm accurate if I'm not accurate I would want to know that. So I don't know if Nissa, I think, perhaps in our exchanges you may have spoken to that or, you know, email exchange. Can can you speak to that or I don't know who to address this to add your Nissa. We'll go ahead, go ahead, Nissa. Thank you for the record Nissa James, Department of Vermont Health Access. Let me just check and make sure that everything is good on the screen and changing speakers since it's been predominantly Emily and Addie. Addie, are we okay? I believe so. Fantastic. So there have been a couple of questions posed and my colleague at DFR has handled all of those questions beautifully but as the chair indicated it is it is important for Vermont Medicaid to go on the record for a couple of different applications. One, first and foremost, Vermont Medicaid does provide coverage for audiology services. And when we say audiology services, this means services related to the diagnosis, screening, prevention, and correction of hearing and hearing disorders. The Medicaid also provides coverage for hearing aids, and this is defined in rule as meaning wearable instruments or devices to compensate for impaired hearing. Under the covered services, audiology services are further detailed to mean audiologic examination, hearing screening, hearing assessments and diagnostic tests for hearing loss. And coverage for hearing aids comprises the categories that my DFR colleague had referred to health insurance being able to implement related to analog or digital hearing aids plus their repair, replacement and modification prescriptions for hearing aid batteries. This would be an area where Vermont Medicaid does provide coverage for hearing aid batteries, sitting orientation and checking of hearing aids, and also your mold specific to hearing aids. The second question was related to the clinical criteria that are in place for conditions for coverage of hearing aids. And specific to our clinical coverage criteria, it's for those who are over the age of 21 and have hearing loss to various degrees. For children under the age of 21, the criteria is that the hearing aid is medically necessary. There's one point of clarification that I would like to provide related to what you heard in terms of the coverage being every three years for a hearing aid for each year. There is the ability to use a prior authorization if additional coverage needs to be explored prior to that three-year limit. I don't want anyone to walk away thinking that because there is that three-year limit, there's not an alternative method for exploration if needed. I think I had all three questions, but let me stop there because I'm sure that may have generated others. This is the chair, Bill Liburd. Thank you, Nissa. I would like to just further clarify the last statement that you made, which I think is important and helpful to understand. Am I with that? There could be further coverage, if you will. Maybe I want to make sure I understand that if there was additional significant change in hearing loss before a three-year period or something akin to that or related that you could there could be further benefit if it was determined through a prior authorization to be medically necessary. Am I understanding that even close? So this is documented in our provider manual and I can send this to the committee if it would be helpful, but we do make sure that providers are aware that there is an opportunity to use the prior authorization process to submit requests if there's a medical necessity or clinically appropriate need prior to that three-year limit. So it would be the provider approaching Vermont Medicaid to make the recommendation of a medically necessary change prior to the full three-year period. Is that correct? That's correct. Okay, that's helpful to understand. I was just curious, how hard of hearing or how much hearing loss does one have to have in order to qualify for assistance with hearing aids? Sure. So for those patients who are over the age of 21, the hearing loss in the better year is greater than 30 decibels and based on an average taken at 500, 1,000 and 2,000. Unilateral hearing loss would also be a criteria and that's when it's greater than 30 decibels and it's again based on an average taken or it's hearing loss in the better year is greater than 40 decibels, but it's based on an average taken at slightly different. So it's 2,000, 3,000 and 4,000 or word recognition is poorer than 72%. Thank you. I think that's, we were joking with each other a little bit that you gave us the correct answer and it's more technical than we're able to comprehend right now. So maybe we'll explore that again another time and another way. Yeah, I was wondering if you could keep data on how many prior lots have been requested and how many are approved. You know, I don't know the answer to that off the top of my head that is a great question and I'm happy to take that back and see if we could disaggregate data in our prior authorization system to break it down to that level. I would just say as an aside, I'm guessing this is motivated in part by our committee's interest in the administrative burden of prior authorizations generally throughout the medical system. We have some initiatives underway, we've tried to have some initiatives underway to try to see whether they are in fact effective and useful or become an administrative burden for providers. It's just, if I may, an opportunity to say that you do it but it doesn't really happen either. The other side of that question. Okay, I think representative Hovind has a question. Yes, I'm going to change Woody's question a little bit but maybe try to get to the same goal which like what do you can tell me if I'm wrong but. Do you hear complaints that it is hard for people who need hearing aids to actually receive them because of the medical necessity. Is it easy for people who need hearing aids? That's a great way to reframe the question. And I will share that no, we have not received any constituent or provider complaints into the diva commissioner's office related to access. So that's first and foremost. Second, I would say that in consultation with our clinical operations team when H266 was released, we crosswalked our coverage to what was in H266 of 2021 and did not determine that that would impact what we're currently doing. So that's also point two to now. And as part of that process further getting to your question rep Houghton, our chief medical officer did contact several of his colleagues to specialize in audiology to make sure that the references that we had used in determining clinical criteria as an example. We're still up to date and appropriate and there weren't recommendations for revising that clinical criteria. So for all of those reasons I'm comfortable saying no we are not hearing that currently. Thank you. Okay, this is all I think this is very helpful and I think we've, did you have further questions? Okay. I'm sorry, can I just clarify, please. I just want to make sure for those listening that that question was directed to diva for Medicaid. So that is the Medicaid response not necessarily other entities other insurance. EHR this whole. Thank you. Thank you, Rob Houghton. This is James representing Vermont Medicaid. Thank you. Right. Okay, so one of the questions was, and this is going. Actually, I don't know if Nissa has this, or at least drama has the numbers available for the number of Vermonters covered by Vermont Medicaid this benefit in Vermont. But let me say what I'm interested in, and Nolan, Nolan Langwell from the Joint Fiscal Office of Legislative Joint Fiscal Office is on the screen and I had, I'm anticipating I'm wanting to ask him to replicate a chart, which we've seen in the past which shows which net which which health insurance types of health insurance represent how many covered lives in Vermont. Because the reason I wanted to have this as kind of foundational information for taking a look at H266, which we will do next Thursday is that we also need to understand, we all collectively need to understand and we as legislators need to understand where the impact is currently and which Vermont lives are covered by which types of insurance coverage and which parts of insurance coverage we have any impact we can have any impact on and which we cannot and where we can have an impact what it requires. It's a much more nuanced and somewhat complicated framework than is necessarily obvious at the outset and some of us had to come to terms with that as we sit on this health care committee. So Nolan, if you can if you understand what I'm asking you had a pie chart in your health care 101 that at the time had emerged small group and individual market but if you would update that for us and indicate the differing numbers of Vermont lives as best you know in round figures. I think that would be helpful then when we look at the bill next Thursday to understand where benefits exist currently where benefits don't exist, etc and understand where we can influence things and where we may not be able to. So, I appreciate. Thank you for thank you. Emily, Addie. Is there anything you wish to add I'm happy to have you've been with us but we didn't direct any questions to you today other days we've directed lots of questions to you. Is there anything that you wish to comment on at this point or, if not that's fine too. Thank you for the opportunity for the record enough back as director of health care reform at the agency of human services and I will only comment briefly that the director of health care reform does have a role in this process in the coordination of the effort across the agencies and departments that are involved, and that we are very pleased with the process on the whole, and pleased to be offering the recommendations here for you today. Thank you. Thank you. And this whole process of particularly the essential health benefits process is a has been, as someone said a long time coming. This has been talked about thought about for many years, and it was only last year as our committee inquired about what was possible as we were working and talking with the Department of Financial Regulation and the Department of Health Access that way. Thank you for having your young person join us it's lovely. It brings the screen considerably. Really lovely, really lovely. Brian join you. Oh no, he's right. That's lovely. Thank you actually we all need a good smile. But just to say that the, again this the process of getting to where there's a recommendation now in front of the Green Mountain care board for updating the essential health benefits within the qualified health plans. I believe is a significant achievement and it's only so they've been able to be achieved by the incredible work from the Department of Financial Regulation from diva and others in the agency to coordinate all this. We will then be looking to the Green Mountain care board. Hopefully to approve this change, and we'll be we'll want to hear from them as well, because they ultimately have, they may be part of the process that I don't yet understand that will be revealed when we talk to them. So with that, I think we'll. This is very useful to understand what the Medicaid Vermont Medicaid benefit is currently and how that mirrors or interacts with the essential health benefits. So with that, I think we'll stop for this part of the afternoon. Thank you all for being part of this. Thank you Corey for your assistance. Sorry about the bumps along the way at the beginning where we will be more adept, hopefully, next Thursday. Perhaps you'll join us or perhaps one of your colleagues will and thank you to the transcriptionist to in the background is making what we're doing more accessible as well. With that, I'm going to suggest Claire that we will go off live.